Pleomorphic xanthoastrocytoma

Pleomorphic xanthoastrocytoma
	Diagnosis in short
	; Pleomorphic xanthoastrocytoma.
LM	marked nuclear atypia, eosinophilic granular bodies - very common, inflammation (chronic), no necrosis
Site	brain - typical temporal lobe
Clinical history	seizure, children & young adults

Pleomorphic xanthoastrocytoma, abbreviated PXA, is neuropathology tumour classically associated with seizures in children.

General

Features:

Rare (less than 1% of all astrocytic tumors).
Classically in the temporal lobe in children and young adults.
Associated with seizures.
Moderately aggressive (WHO Grade II).^[1]
Anaplastic PXA (grade III) - rare. ^[2]
ICD-O: 9424/3.

Gross

Temporal lobe - classic.
Usually assoc. with the leptomeninges,^[1] i.e. superficial (in up 96%).

Typical appearance is one of a superficially situated tumor, here a mural nodule, associated with an underlying cyst (AFIP)
Hemorrhagic pleomorphic xanthoastrocytoma (PXA), MRI (WC/RadsWiki)

Microscopic

Features:^[3]

Fibrillary background.
Large cells with marked nuclear atypia.
Multinuclear cells possible.
Reticulin meshwork.
Lipidized cells.
Eosinophilic granular bodies - very common.^[1]
Inflammatory cells (lymophocytic perivascular cuffs).

Grading

Grade II: Mitotic activity is low, no necrosis.
Grade III anaplastic PXA: more than 5/10 HPF, may have necrosis.

Notes: Anaplastic PXA was introduced in the WHO2016 revision as a distinct entity. In the past, the tumor was called PXA with anaplastic features.

DDx:

Images

HE smear of a PXA. (WC/AFIP)
HE intraoperative frozen section of PXA. (WC/jensflorian)
The tumor is aptly named due to ist pleomorphic cells. HE, high magnification. (WC/marvin101)
The pleomorphic cells must not be confused with a higly anaplastic glioma. HE, intermed magnification.(WC/jensflorian)
Focal xanthomatous cells as in the name PXA. HE, intermed magnification.(WC/jensflorian)
Perivascular lymphocytic cuffs are not uncommon. HE, intermed-low magnification.(WC/jensflorian)
Eosinophilc granular bodies in a PXA. HE, intermed magnification.(WC/jensflorian)
A delicate meshwork of retiulin fibers in PXA. Gomori, intermed magnification.(WC/jensflorian)
GFAP IHC is often heterogenous in PXA. Intermed magnification.(WC/jensflorian)
HE of anaplastic PXA.

www:

Stains

Reticulin stain - intercellular, prominent.^[4]

Image:

PXA - several images (nih.gov).^[4]

IHC

GFAP +ve.
S-100 +ve.
CD68 +ve.
CD34 frequently.
MAP2+ve and Synapto+ve pleomorphic cells
MIB-1 usually low.

Molecular

BRAF V600E mutation in 2/3 of the cases^[5]
- (mostly in temporal, reticulin-fiber rich tumors)^[6]

References

↑ ^1.0 ^1.1 ^1.2 Fouladi, M.; Jenkins, J.; Burger, P.; Langston, J.; Merchant, T.; Heideman, R.; Thompson, S.; Sanford, A. et al. (Jul 2001). "Pleomorphic xanthoastrocytoma: favorable outcome after complete surgical resection.". Neuro Oncol 3 (3): 184-92. PMID 11465399.
↑ Louis, DN.; Perry, A.; Reifenberger, G.; von Deimling, A.; Figarella-Branger, D.; Cavenee, WK.; Ohgaki, H.; Wiestler, OD. et al. (Jun 2016). "The 2016 World Health Organization Classification of Tumors of the Central Nervous System: a summary.". Acta Neuropathol 131 (6): 803-20. doi:10.1007/s00401-016-1545-1. PMID 27157931.
↑ Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson; Aster, Jon (2009). Robbins and Cotran pathologic basis of disease (8th ed.). Elsevier Saunders. pp. 1333. ISBN 978-1416031215.
↑ ^4.0 ^4.1 Dias-Santagata, D.; Lam, Q.; Vernovsky, K.; Vena, N.; Lennerz, JK.; Borger, DR.; Batchelor, TT.; Ligon, KL. et al. (2011). "BRAF V600E mutations are common in pleomorphic xanthoastrocytoma: diagnostic and therapeutic implications.". PLoS One 6 (3): e17948. doi:10.1371/journal.pone.0017948. PMID 21479234.
↑ Schindler, G.; Capper, D.; Meyer, J.; Janzarik, W.; Omran, H.; Herold-Mende, C.; Schmieder, K.; Wesseling, P. et al. (Mar 2011). "Analysis of BRAF V600E mutation in 1,320 nervous system tumors reveals high mutation frequencies in pleomorphic xanthoastrocytoma, ganglioglioma and extra-cerebellar pilocytic astrocytoma.". Acta Neuropathol 121 (3): 397-405. doi:10.1007/s00401-011-0802-6. PMID 21274720.
↑ Koelsche, C.; Sahm, F.; Wöhrer, A.; Jeibmann, A.; Schittenhelm, J.; Kohlhof, P.; Preusser, M.; Romeike, B. et al. (Apr 2014). "BRAF-mutated pleomorphic xanthoastrocytoma is associated with temporal location, reticulin fiber deposition and CD34 expression.". Brain Pathol 24 (3): 221-9. doi:10.1111/bpa.12111. PMID 24345274.

[pmid11465399-1] 1.0 ^1.1 ^1.2 Fouladi, M.; Jenkins, J.; Burger, P.; Langston, J.; Merchant, T.; Heideman, R.; Thompson, S.; Sanford, A. et al. (Jul 2001). "Pleomorphic xanthoastrocytoma: favorable outcome after complete surgical resection.". Neuro Oncol 3 (3): 184-92. PMID 11465399.

[2] Louis, DN.; Perry, A.; Reifenberger, G.; von Deimling, A.; Figarella-Branger, D.; Cavenee, WK.; Ohgaki, H.; Wiestler, OD. et al. (Jun 2016). "The 2016 World Health Organization Classification of Tumors of the Central Nervous System: a summary.". Acta Neuropathol 131 (6): 803-20. doi:10.1007/s00401-016-1545-1. PMID 27157931.

[Ref_PBoD8_1333-3] Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson; Aster, Jon (2009). Robbins and Cotran pathologic basis of disease (8th ed.). Elsevier Saunders. pp. 1333. ISBN 978-1416031215.

[pmid21479234-4] 4.0 ^4.1 Dias-Santagata, D.; Lam, Q.; Vernovsky, K.; Vena, N.; Lennerz, JK.; Borger, DR.; Batchelor, TT.; Ligon, KL. et al. (2011). "BRAF V600E mutations are common in pleomorphic xanthoastrocytoma: diagnostic and therapeutic implications.". PLoS One 6 (3): e17948. doi:10.1371/journal.pone.0017948. PMID 21479234.

[5] Schindler, G.; Capper, D.; Meyer, J.; Janzarik, W.; Omran, H.; Herold-Mende, C.; Schmieder, K.; Wesseling, P. et al. (Mar 2011). "Analysis of BRAF V600E mutation in 1,320 nervous system tumors reveals high mutation frequencies in pleomorphic xanthoastrocytoma, ganglioglioma and extra-cerebellar pilocytic astrocytoma.". Acta Neuropathol 121 (3): 397-405. doi:10.1007/s00401-011-0802-6. PMID 21274720.

[6] Koelsche, C.; Sahm, F.; Wöhrer, A.; Jeibmann, A.; Schittenhelm, J.; Kohlhof, P.; Preusser, M.; Romeike, B. et al. (Apr 2014). "BRAF-mutated pleomorphic xanthoastrocytoma is associated with temporal location, reticulin fiber deposition and CD34 expression.". Brain Pathol 24 (3): 221-9. doi:10.1111/bpa.12111. PMID 24345274.

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Pleomorphic xanthoastrocytoma

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